Recipient Enrollment and Disenrollment Sample Clauses

Recipient Enrollment and Disenrollment. A. Recipient Enrollment 1. The PMP must accept individuals in the order in which they apply without restriction up to the limits set by the agreement. The PMP may specify a limit on the number of enrollees on the Patient 1st Application for Participation subject to the following terms and conditions:  Maximum enrollment is set at 1200 enrollees per physician unless otherwise approved by the Agency. An additional 400 enrollees per physician extender (up to 2) will be allowed.  The PMP may set enrollment criteria on the Application, but must accept recipients who meet the enrollment criteria up to the limit specified.  The PMP may change the enrollee limit by notifying the Agency in writing and/or its representative.  The PMP must restrict enrollment to recipients who reside sufficiently near the delivery site to reach that site within a reasonable time using available and affordable modes of transportation. B. Recipient Choice 1. Eligible recipients may choose from among participating PMPs’ who are available within the Health Home distance from their residence when those PMPs’ enrollment limits have not been exceeded. 2. All recipient enrollments, disenrollments, and changes are effective on the first day of the month, pursuant to processing deadlines and will be indicated on the Enrollment Reports. C. Recipient Disenrollment 1. Enrollees shall be permitted to change primary care providers according to Patient 1st policy. Transfer of medical records is addressed in Section 4.8 of this agreement. 2. The PMP may request the disenrollment of an enrollee for good cause as defined by Patient 1st policy. 3. The PMP may not request disenrollment because of an adverse change in the enrollee’s health status, or because of the enrollee’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment with the PMP seriously impairs the PMP’s ability to furnish services to either this particular enrollee or other enrollees). 4. The Patient 1st Medicaid Managed Care Recipient Handbook includes complaint and grievance instructions and are provided to potential enrollees and enrollees. This handbook is also published on the Agency’s website at ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇.▇▇▇▇▇▇▇.▇▇▇.
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Recipient Enrollment and Disenrollment 
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Related to Recipient Enrollment and Disenrollment

  • Disenrollment 12.1 ADFMs shall be disenrolled from TOP Prime/TOP Prime Remote, TOP Select when: • The enrollee loses eligibility for TOP enrolled coverage, • The enrollee has not requested enrollment transfer/disenrollment of TOP Prime/TOP Prime Remote within 60 calendar days following the end of the overseas tour. 12.2 ADSMs shall be disenrolled from TOP Prime/TOP Prime Remote when: 12.3 ADFMs who are enrolled in TOP Prime/TOP Prime Remote may disenroll at any time. They will not be permitted to make another enrollment until after a 12-month period if they have already changed their enrollment status from enrolled to disenrolled twice during the enrollment year (October 1 to September 30) for any reason. ADFMs with sponsors E-1 through E-4 are exempt from these enrollment lock-out provisions. See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. Effective January 1, 2018, see TPM, Chapter 10, Section 2.1 for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames. 12.4 ADSMs cannot voluntarily disenroll from TOP Prime or TOP Prime Remote if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP Prime Remote continues until they transfer enrollment to another TRICARE region/program or lose eligibility for TOP/TRICARE. 12.5 TOP Prime/TOP Prime Remote enrollees must either transfer enrollment or disenroll within 60 calendar days of the end of the overseas tour when the ADSM departs to a new area of assignment. The TOP contractor shall provide continuing coverage until (1) the enrollment has been transferred to the new location, (2) the enrollee disenrolls, or (3) when enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th day the TOP contractor will automatically disenroll the beneficiary on the 61st calendar day following the end date of the overseas tour from TOP Prime or TOP TPR. Until December 31, 2017, the disenrolled ADFM TOP Prime or TOP TPR beneficiary will revert to TRICARE Standard. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at military treatment facilities.‌

  • Enrollment You are responsible for i) having all of the required information in this Agreement completed and

  • Enrollment Process The Department may, at any time, revise the enrollment procedures. The Department shall advise the Contractor of the anticipated changes in advance whenever possible. The Contractor shall have the opportunity to make comments and provide input on the changes. The Contractor shall be bound by the changes in enrollment procedures.

  • Open Enrollment KFHPWA will allow enrollment of Subscribers and Dependents who did not enroll when newly eligible as described above during a limited period of time specified by the Group and KFHPWA.

  • Special Enrollment a. KFHPWA will allow special enrollment for persons: 1) Who initially declined enrollment when otherwise eligible because such persons had other health care coverage and have had such other coverage terminated due to one of the following events: • Cessation of employer contributions. • Exhaustion of COBRA continuation coverage. • Loss of eligibility, except for loss of eligibility for cause. 2) Who initially declined enrollment when otherwise eligible because such persons had other health care coverage and who have had such other coverage exhausted because such person reached a lifetime maximum limit. KFHPWA or the Group may require confirmation that when initially offered coverage such persons submitted a written statement declining because of other coverage. Application for coverage must be made within 31 days of the termination of previous coverage. b. KFHPWA will allow special enrollment for individuals who are eligible to be a Subscriber and their Dependents (other than for nonpayment or fraud) in the event one of the following occurs: 1) Divorce or Legal Separation. Application for coverage must be made within 60 days of the divorce/separation. 2) Cessation of Dependent status (reaches maximum age). Application for coverage must be made within 30 days of the cessation of Dependent status. 3) Death of an employee under whose coverage they were a Dependent. Application for coverage must be made within 30 days of the death of an employee. 4) Termination or reduction in the number of hours worked. Application for coverage must be made within 30 days of the termination or reduction in number of hours worked. 5) Leaving the service area of a former plan. Application for coverage must be made within 30 days of leaving the service area of a former plan. 6) Discontinuation of a former plan. Application for coverage must be made within 30 days of the discontinuation of a former plan. c. KFHPWA will allow special enrollment for individuals who are eligible to be a Subscriber and their Dependents in the event one of the following occurs: 1) Marriage. Application for coverage must be made within 31 days of the date of marriage. 2) Birth. Application for coverage for the Subscriber and Dependents other than the newborn child must be made within 60 days of the date of birth. 3) Adoption or placement for adoption. Application for coverage for the Subscriber and Dependents other than the adopted child must be made within 60 days of the adoption or placement for adoption. 4) Eligibility for premium assistance from Medicaid or a state Children’s Health Insurance Program (CHIP), provided such person is otherwise eligible for coverage under this EOC. The request for special enrollment must be made within 60 days of eligibility for such premium assistance. 5) Coverage under a Medicaid or CHIP plan is terminated as a result of loss of eligibility for such coverage. Application for coverage must be made within 60 days of the date of termination under Medicaid or CHIP. 6) Applicable federal or state law or regulation otherwise provides for special enrollment.